Strengthened access to Basic Nutrition and Health Services, Governance and Resilience for improved service delivery to children and families in Bardhere and Belet-Hawa districts of Gedo Region of Somalia
An estimated 2.7 million people in Somalia remain in food emergency and at risk of sliding into severe critical levels. This is largely a consequence of protracted war and ravages of cyclic drought experienced in South and Central parts of the country in the last three years. The combined effect of the two has left a trail of adverse nutritional outcomes manifested in wide spread Severe and Global acute malnutrition rates surpassing the emergency threshold in select geographical locations. Apart from food security, poor nutritional status is aggravated by diarrheal diseases emanating from poor sanitation and hygiene practices and coupled weak and unresponsive health system.
Bardhera and Belet-Hawa are part of the Southern region associated with some of the worst nutritional indicators in the Country. FSNAU reports 2017 found Dollow and nearby Dollow IDPs (Next to Belet- Hawa) to have the worst nutritional indicators Global Acute Malnutrition rates (GAM 22.5%) in the whole country. The latest report indicates an improvement to 13.9 % with pastoral and riverine communities with malnutrition rates of 15.7% and 14.9% respectively. A slight improvement in nutritional status, especially among pastoralists has been attributed to intense humanitarian assistance. With more focus on livelihoods or health sector response, substantial improvements could have resulted. The nutritional status of Bardhera communities has been relatively stable even as other regions were recording slight improvements towards end of 2017. The proportion of malnourished children (GAM) ranged from 10-15 percent. With already critical and near critical nutritional status in the targeted areas of Belet-Hawa and Bardera, the below average Gu rain forecast is likely to worsen the situation.
The cumulative effect of malnutrition in Bardera is worse than other regions due to access restrictions experienced for some time. Resultant from this is limited health sector response despite its criticality in addressing malnutrition from multifaceted perspectives. From prolonged and recurrent shocks, significant proportions of children require nutritional rehabilitation and other treatment interventions that go beyond food provision. HIRDA with the support UNICEF will collectively address the related nutrition problems identified in the rationalized area.
HIRDA is a prominent CSO with a diverse knowledge of the local context especially Bardhere and Balet-Hawa Districts where it has implemented a number of PCAs with UNICE in the areas of; Health, Education, and Nutrition using a community based friendly approach. The programs mainly target the wellbeing of Pregnant and Lactating Women (PLW), Severe Acute Malnutrition (SAM), Moderate Acute Malnutrition (MAM) with complications in children across the two districts alongside other preventive and curative programs. HIRDA is implementing the resilience program with the aim of improving communities’ knowledge and resistance to shocks both manmade and natural which result in communities appreciating the local available resource with the help of CDC established across all the OTP sites and CWs. The main project activities include;
- Implementation of a full package of Community and Facility Based Nutrition, Health and WASH services across 27 Sites (26 OTP sites both fixed and mobile,1 MCH);
- Identification, referral and treatment of children suffering from Severe Acute Malnutrition (SAM) through Community, Facility approached HIRDA OTP mobile Teams.
- Referral of complicated cases of SAM to HIRDA stabilization centre for emergency service delivery and after stabilization, referral back to HIRDA OTP sites for further treatment, the community-based facility covers the minimum 5 Pages of BNSP including Curative and Preventive intervention targeting, Chidden U5 years (Boys and Girls) and Pregnant and Lactating Women (PLW).
- Mother led MUAC approach to identify and diagnose malnutrition by mothers. Mothers use MUAC tapes to measure the Mid-Upper Arm Circumference (MUAC). Mother led MUAC training conducted to support mothers to screen, detect oedema and self-referral of their children to nutrition sites.
- Management of 27 Sites in the two Districts; Baled-hawa (10 OTP Mobile sites and 2 fixed OTP site) and Bardhere (14 Mobile sites, 2 Fixed OTP site and 1 SC) where both MAM and SAM services are offered. HIRDA will ensure to strengthen the integration of OTP and TSFP sites where possible to ensure the sustainability of IMAM interventions and the technical local capacity strengthened for integratin of IMAM into the Primary Health Care system through the functional MCH facilities. Additionally, the capacity of nutrition staff will be strengthened for effective service delivery at facility and community level. In coordination with the Child Protection section, survivors of gender-based violence (GBV) identified at the nutrition sites and catchment areas, will be referred to multi-sectoral services.
- Prevention services include
- Provision of routine immunization services to children and pregnant women in these project catchments through its both fixed and mobile OTP. Community health workers will conduct systematic defaulter tracing at community level.
- Deworming for children 12-59 months and pregnant women in the 2nd and 3rd trimester, counselling and promotion on infant and young child feeding. Community mobilization and screening
- Micronutrient supplementation for PLW (multiple micronutrients and Iron folate) and children 6-59 months with Vitamin A supplements. The program will promote home based fortification to enrich the diets of young children 6-23 months through the distribution of micronutrient Powders.
- Community Resilience approach overlaid with basic service provision of key Health, WASH and Nutrition basic services for prevention, promotion and referral and done by trained community workers. The community-based workers will be channeled through service committees such as community development committees (CDCs). Community consultation and action planning supporting the delivery of community based public health interventions including monitoring open defecation (ODF) and hand washing practices at critical times.
- Managing 1 MCH in Belet-Hawa District to provide Maternal, newborn and child health care services and Prevention, control and management of communicable diseases to 183,530 people in Bardera and Garbaharey Districts where;
- Children under-five vaccinated against measles in the targeted two Districts.
- Pregnant and lactating women receive focused ANC and PNC services in the targeted districts.
- HIRDA ensures availability of medicines and vaccines in the supported health facilities
The table below summarizes the project progress by output and activity in each category.
|Output||Activity (Please detail activities)||Indicators||Program Target||Achievement:|
September 2019-March 2020
|CUMMULATIVE achievement (start of program to date)||Comments|
|Output 1 |
Increased availability of basic services delivered at facility and community levels
|Treatment of severe acute malnutrition||No. of IMAM sites integrating MAM and SAM treatment||27 Sites:|
4 fixed sites and 23 mobile sites
4 fixed sites and 23 mobile sites
4 fixed sites and 23 mobile sites
|Monthly Progress Reports; This has been set up and achieved as per Program Document (PD)|
|Number and Proportion of severely malnourished children (6-59 months) admitted for treatment||6,786 100%||2,975 or 48%||4,060 or 66%||Monthly Report; with the help of a well trained and experienced nutrition staff, HIRDA has admitted and treated 2,975 severely malnourished children in Bardere and Beled Hawa Districts of Gedo Region in the last 6 months.|
|Prevention of malnutrition among children and PLWs||No. of children (6-23 months) receiving nutrition support throughout the year to prevent malnutrition||10,000||4,792 or 48%||71,57 or 72%||Facility Reports; 4,792 young children have so far received nutrition support in order to prevent malnutrition.|
|Service delivery of basic nutrition package by health workers, community based workers and women support groups and community development committees at facility and community level||No. of women delivering at the health facility receiving food support||2,450 PD target||1,122 or 46%||1,734 or 71%||Facility Reports; the women delivering at the health facility as a result of the food support provided at during MCH/ANC visits has increased|
|No. of health facilities (at least 80% of target) providing the package of services (health nutrition and WASH) by 2020||10||10 (100%)||10 (100%)||Monthly Reports; in order to reach many people in the accessible areas, we have established 18 health facilities in the two districts. This has expanded our nutrition program hence lowering the malnutrition level in the Districts.|
|No. of health facilities (at least 80% of target) facing no stock out of key commodities for health, WASH and Nutrition||10||10 (100%)||10 (100%)||Facility Reports; we received supplies from UNICEF in good time during the quarter hence no stock outs were reported by the health facilities.|
|No. of health facilities (at least 80% of target) with skilled personnel in the provision of nutrition, WASH and health services||10||10 (100%)||10 (100%)||Monthly Report; 80 well trained nutrition staffs in the two districts are involved in the provision of the nutrition, WASH and health services.|
|Prevention and management of common illnesses (anaemia, malaria, diarrhoea, pneumonia)||No. of children under 1 year old immunized for Penta 111||8,698||4,150 or 48%||6,114 or 70%||Facility Reports/Monthly report|
|No. of children (6-59 months) receiving two doses of vitamin A in a year||8,675||3,890 or 45%||5,654 or 65%||Facility Reports/Monthly report|
|Output 2 Communities, households and individuals are engaged in the delivery of basic services, leading to improved knowledge, attitudes and practices that support better choices||Promotion and support for optimal maternal and nutrition and care||No. of community dialogues and public forums||12||6 or 50%||10 or 83%||Monthly report|
|No. of community action plans developed||12||6 or 50%||10 or 83%||Monthly report: Community action plans are developed on monthly bases, we therefore, had 6 CAPs in the last 6 months|
|No. of households in the targeted communities receiving services from a community based worker||13,981|
8,381 Beled Hawa
|7,205 or 52%||10,490 or 75%||Monthly report; we are on track in achieving the target in this line, by the end of the PD we would have achieved almost our target in the service delivery at the two districts of Gedo region.|
|No. of community based workers (male/female) trained on nutrition screening and delivering services||180||25 CWs were trained in Beled Hawa district|
|159 or 88%||Monthly Report; the CBWs were recruited and trained and actively involved in screening and passing important information to the community members. We are planning to train the remaining 46 CBWs in the next quarter.|
|Micronutrient support||No. of PLW receiving multiple micronutrients||7,580||3,587 or 47%||5,422 72%||Monthly Reports; Based on PLW attending ANC services.|
|No. of children (6-23 months) receiving multiple micronutrient powders||27,459||13,265 49%||16,850 or 61%||Monthly Report; This is low due to the delay in IMAM training. Will pick up once the training is done.|
|Promotion and support for optimal IYCF||Number and Percentage of PLW receiving at least one IYCF counselling||12,388 (>75%)||6,025 or 48%||7,990 or 65%||Monthly Reports; the target is based on the cumulative figure hence the current low percentage|
|Output 3: Strengthened community governance and management for provision of basic services||Capacity building of governance systems to steward basic services at community level||No. of mother support groups established||27||27||27||Monthly Reports; All groups have been established and are operational as designed in the Program Document.|
|No. of mother support group sessions conducted||400||192 or 48%||285 or 72%|
|No. of transparently elected CDCs||35 CDCs|
20 in Bardere
15 in Beled Hawa
20 in Bardere
15 in Beled Hawa
20 in Bardere
15 in Beled Hawa
|Monthly reports; the CDCs elections were conducted early as project inception.|
|No of community action plans developed||16 |
8 in Bardere
8 in Beled Hawa
|Monthly Reports; 2 communities in each district have developed their action plans. 8 action plans were developed from September to March|
|No and percent of action plans implemented by CDCs||16|
|Monthly Reports; the CDCs have done well in working closely with the CBWs and linking the community to the nutrition services and to the community and facility based services.|
CONSTRAINTS AND LESSONS LEARNT
Community Misunderstanding; when we launched the program, there was little information on the importance of nutrition and resilience project. Additionally, the community members did not understand the role of these community-based workers (CBWs), however, with engagement and awareness sessions conducted in the community, the community members have now accepted and are collaborating well with the CBWs and are receiving the health/nutrition/WASH services provided by the community based workers
Late reporting by CBWs; the role of the CBWs were not well understood by the communities hence their resistance in providing information to the CBWs and thus delaying reporting in the first month. However, with the help of the CDCs we resolved the challenges and we are now at the right direction with the provision of the health and nutrition services to the communities at the two districts which are Bardere and Beled Hawa of Gedo region
Budget release; the budget is released in tranches on a quarterly basis and based on an equal division of the annual budget yet some of the activities like training require lump sum expenditure at some points. This may sometimes have delayed the implementation of the nutrition program at the districts of operation.
The challenges were mitigated through consultations and advice from the director coupled with efforts from the nutrition coordinators and the field officers.
KEY PARTNERSHIPS AND INTER-AGENCY COLLABORATION
HIRDA is collaborating with the local authorities in both districts of Bardera and Beled Hawa, the local authorities are involved and informed at all the stages of implementing the nutrition and health services, for instance, they are invited and involved whenever there is a meeting or training so that they officially open and know what is going on in the District. The local authorities were also visited and briefed before launching the program and thus made them feel appreciated
HIRDA is also collaborating well with the local/national and international NGOs operating in Bardere district, for instance, we admit children transferred from other nutrition centers like SRCS, IOM (Implementing health services in Bardere district hospital) in our facilities without discrimination. The other organizations also refer severely malnourished children with complications to HIRDA’s stabilization center in Bardere town. This coordination and communication between HIRDA and other agencies had greatly contributed to a better service delivery in the districts and the local authorities have appreciated and hailed the work done by the NGOs.
Accomplishments and learning
In addition to the already recruited and trained 134 CBWs in both districts, we trained 26 new CBWs in Beled Hawa alone, which was a great achievement worth mentioning; we also trained 25 nutrition staff on IMAM protocol in each of the two districts we operation and we also trained 10 IYCF who will all contribute to better nutrition and health service provision in both districts.
We have learnt the importance of the resilience program in delivering nutrition services to the community. These have resulted in many people being aware of the nutrition services and it has increased the number of children seeking for treatment in the nutrition and health centers. This is so because people are informed about the services available in areas of operation therefore resilience program has played a vital role in the implementation of nutrition program in the two districts. We have accomplished the following in our districts of operation.
We worked differently in a number of ways; we organized meetings with all the CBWs in all sites so that important information could be shared. During the meetings those who had experienced challenges were given support in order to overcome the challenges and do their work properly. The community appreciated the training they received and were ready to work with community-based workers. The community is hardworking and welcoming and they are ready to help their vulnerable groups in the district. The program has resulted local ownership because HIRDA has involved the community in all activities in the districts which gave them the confidence that the program is theirs.